| NPI | 1558568436 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CO 1657) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: SD 454) |
| Enumeration Date | 2007-07-02 |
| Last Update Date | 2007-07-09 |